Case ID: ____________
Address Line 1
Address Line 2
City, State, Zip code
Dear (Mr. or Ms.) (Last name):
We are the office that makes disability decisions for the Social Security Administration.
We received your claim for disability. We will decide if you qualify for disability
benefits. To be eligible for disability benefits, you must meet our rules. You must
have a medical condition(s) that keeps you from doing any type of work, and has lasted
or is expected to last for at least 12 months in a row or result in death. Since your
____occurred so recently, we will need to know what your condition is as of ____.
We will make every effort we can to get the requested information before we make a
decision on your claim.
Toll Free: 1-800-XXX-XXXX, extension XXXX